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VERY SERIOUS MARINE CASUALTY REPORT NO 19/2018 NOVEMBER 2018

Report on the investigation of the

fatal man overboard from fishing vessel

North Star

16nm north of Cape Wrath, Scotland

5 February 2018

Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident

Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents

through the ascertainment of its causes and circumstances. It shall not be the purpose of an

investigation to determine liability nor, except so far as is necessary to achieve its objective,

to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the

Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be

inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to

attribute or apportion liability or blame.

Front cover image courtesy of the Maritime and Coastguard Agency

© Crown copyright, 2018

You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.gov.uk/maib

For all enquiries:Marine Accident Investigation BranchFirst Floor, Spring Place105 Commercial RoadSouthampton Email: maib@dft.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 1GH Fax: +44 (0) 23 8023 2459

Press enquiries during office hours: 01932 440015Press enquiries out of hours: 020 7944 4292

CONTENTS

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

SYNOPSIS 1

SECTION 1 - FACTUAL INFORMATION 2

1.1 Particulars of North Star and accident 21.2 Narrative 3

1.2.1 Background 31.2.2 The accident 41.2.3 The rescue 4

1.3 Environmental conditions 61.4 North Star 7

1.4.1 General 71.4.2 Survey and inspection 7

1.5 Creelfishing 81.5.1 Assemblyofacreelfleet 81.5.2 Vesselmodifications 81.5.3 Creel shooting hazard 11

1.6 Crew 111.6.1 Manning 111.6.2 Qualifications 111.6.3 Senior skipper 121.6.4 Skipper 131.6.5 Mark Elder 131.6.6 Cannabis 13

1.7 Onboard safety 131.7.1 Health and safety general duty 131.7.2 Risk assessment 141.7.3 Emergency preparedness 14

1.8 Coldwaterimmersion 151.9 Skipper/owner responsibilities 151.10 Previous accidents 16

1.10.1 Varuna 161.10.2 Pauline Mary 16

SECTION 2 - ANALYSIS 17

2.1 Aim 172.2 The accident 172.3 Entanglement 17

2.3.1 Entanglement in the gear 172.3.2 Draggedoverboard 18

2.4 Inwatersurvivability 182.5 Therescue 182.6 Safety culture 19

2.6.1 Responsibilities 192.6.2 Risk assessment 20

2.7 Regulatory oversight 202.8 Druguseonboardfishingvessels 21

FIGURES

Figure 1 - The deckhands’ positions on the working deck

Figure 2 - Plan of North Star’s main deck level

Figure 3 - BA Chart 002 showing the location of North Star at the time of the accident, with inset of location on BA Chart 2720

Figure 4 - Image of North Star in the seaway taken from the rescue helicopter video footage

Figure 5 - Creel arrangement

Figure 6 - Former working deck layout

Figure 7 - Modifiedworkingdecklayout

TABLES

Table 1 - North Star’screwqualifications

ANNEXES

Annex A - Extracts from The Code of Safe Working Practices for the Construction and Use of 15m Length Overall (LOA) to less than 24m Registered Length (L) Fishing Vessels

Annex B - ExtractsfromMGN411(M+F)–TrainingandCertificationRequirements for the Crew of Fishing Vessels and their Applicability to Small Commercial Vessels and Large Yachts

Annex C - North Star’s risk assessments for ‘general working on deck’, ‘shooting general’ and ‘potting’

Annex D - Safety Flyer to the Fishing Industry

SECTION 3 - CONCLUSIONS 22

3.1 Safety issues directly contributing to the accident that have been addressed or resulted in recommendations 22

3.2 Other safety issues directly contributing to the accident 233.3 Safety issues not directly contributing to the accident that have been addressed

or resulted in recommendations 23

SECTION 4 - ACTION TAKEN 24

4.1 Actions taken by MAIB 244.2 Actions taken by other organisations 24

SECTION 5 - RECOMMENDATIONS 25

GLOSSARY OF ABBREVIATIONS AND ACRONYMSCCTV - Closed Circuit Television

CPR - Cardiopulmonary Resuscitation

DSC - Digital Selective Calling

kg - kilogram

kts - knots

LOA - Length Overall

m - metre

MAIB - Marine Accident Investigation Branch

MCA - Maritime and Coastguard Agency

MGN - Marine Guidance Note

MSN - Merchant Shipping Notice

nm - nautical miles

PFD - Personal Flotation Device

Seafish - SeaFishIndustryAuthority

SOG - speed over the ground

STCW - InternationalConventiononStandardsofTraining,CertificationandWatchkeepingforSeafarers1978,asamended(STCWConvention)

UKFVC - UnitedKingdomFishingVesselCertificate

UTC - Universal Co-ordinated Time

VHF - Very High Frequency

TIMES: all times used in this report are UTC unless otherwise stated.

North Star

1

SYNOPSIS

On5February2018,atapproximately1815,MarkElder,acrewmanonthe16.46mcreelfishingvesselNorth Star, was dragged overboard after his leg became entangled in the fishinggearasthecrewwereshootingcreels16nmnorthofCapeWrath,Scotland.Thecrew recovered him back on board about 10 minutes later; he was unconscious and unresponsive. The crew carried out cardiopulmonary resuscitation for over an hour, but they were unable to revive him.

The accident occurred because the crewman was working close to running ropes and became entangled in the back rope while engaged in toggling the creels on to the leg ropes. Although the alarm was raised quickly the skipper was unable to stop the vessel in time to prevent the crewman from being dragged overboard.

Thisisoneofanumberofrecentaccidentsinwhichfishermenhavediedafterbecomingentangled in gear when the vessels’ crews have been unable to either prevent them from going overboard or quickly recover them back on board. North Star’s crew had not completed a practical manoverboard drill during their time on board and were ill-prepared for the emergency.

TheMAIBinvestigationfoundthatthevessel’sdocumentedriskcontrolsdidnotreflecttheoperational practice on board, and that the crew underestimated the risks associated with a crewman becoming entangled in the back rope and being dragged overboard. Shooting operationsdidnotfollowpublishedindustrybestpracticetoeffectivelyphysicallyseparatethe crew from the back rope and to have knives at hand. In addition, North Star’s owner wasnewtofishingvesselownershipanddidnottakeaproactiveapproachtoensureregulatory compliance in respect of risk assessment review, vessel inspection and crew qualifications.

North Star’s owner, Scrabster Seafoods Limited, has since installed a physical barrier to reduce the risk of crew becoming entangled in the back rope. The company has also reviewed its risk assessments, ensured its crew have attended mandatory safety training, providedpersonalflotationdevicesonboard,andintroducedadrugandalcoholpolicy.

A recommendation has been made to Scrabster Seafoods Limited, which seeks to further improve the overall safety of its crews. A recommendation has also been made to the Maritime and Coastguard Agency aimed at improving the support and guidance it provides tocommercialfishingvesselowners.

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SECTION 1 - FACTUAL INFORMATION

1.1 PARTICULARS OF NORTH STAR AND ACCIDENT

SHIP PARTICULARSVessel’s name North StarFlag United KingdomClassificationsociety Not applicableIMOnumber/fishingnumbers WK 623Type CreelfishingvesselRegistered owner Scrabster Seafoods LimitedManager(s) Scrabster Seafoods LimitedConstruction SteelYear of build 1996Length overall 18.2mRegistered length 16.46mGross tonnage 150Authorised cargo Not applicable

VOYAGE PARTICULARSPort of departure Scrabster, ScotlandPort of arrival Scrabster, ScotlandType of voyage CoastalCargo information CrabsManning 6

MARINE CASUALTY INFORMATIONDate and time 5February2018atapproximately1820Type of marine casualty or incident Very Serious Marine CasualtyLocation of incident 16nm north of Cape Wrath, ScotlandPlace on board Working deckInjuries/fatalities One fatalityDamage/environmental impact NoneShip operation Shooting creelsVoyage segment Mid-waterExternal & internal environment Wind: south-west 35 knots

Sea: roughTidal stream: north-west 1.5 knotsWater temperature: Approximately 10°C

Persons on board 6

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1.2 NARRATIVE

1.2.1 Background

There were two methods of shooting creels employed on North Star. The self-shooting method, which could be used in sea conditions up to sea state 6, and the manual shooting method. The manual shooting method involved Deckhand 1 moving the creels one at a time from the stow to the launching table where Mark Elder was stationed (Figure 1). Mark then removed a leg rope from the shooting poles and toggled the creel to it before Deckhand 2 moved the attached creel to the vessel’s side ready for it to be launched. Deckhand 3 was stationed at the cutting table, processing the crabs from the previous haul. The skipper was alone in the wheelhouse monitoring the vessel’s speed and the closed circuit television system (CCTV) that showed what was happening on the working deck. There was also a tannoy system that enabled the skipper to communicate with the crew and vice versa.Thesixthcrewmanwasoff-watchandinthecrewmessroom(Figure 2).

Figure 1: The deckhands’ positions on the working deck

Crab cutting area

Shooting poles

Shooting hatch

Launching table

Hauling hatch

Hauler

Back rope

2

1

3

Figure 2: Plan of North Star’s main deck level

Freezer and storage area

Crew mess

Working deck

Crab cutting area

Vivier tank hatch

Shooting hatch Hauling hatch

Stow

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1.2.2 The accident

North StardepartedScrabster,Scotlandjustaftermidnighton2February2018.Itssix crew members expected to remain at sea for up to 10 days before returning to Scrabster to land the catch for processing.

Atabout1815on5FebruaryNorth Star was approximately 16nm north-west of Cape Wrath (Figure 3), following a north-easterly course at a speed over the ground (SOG) of 5 knots (kts). Its engine throttle was set to ‘ahead’. The four deckhands were on the working deck (Figure 2)manuallyshootingafleetofcreelswhentheskipper heard a shout of “Easy”1 over the tannoy. In response, he placed the engine throttle to ‘neutral’, and North Star’s SOG gradually reduced, although the vessel continued to make headway.

Shortly afterwards, the skipper heard a shout of “Stop” and he placed the engine throttle to ‘astern’ to stop the vessel in the water. From the CCTV display, the skipper could see that Mark had been pulled against the launching table, with his left leg entangled in the back rope, which was leading out of the shooting hatch. There was a toggled on creel on the table, ready to be launched overboard. Although Deckhand 2 had grabbed hold of Mark, he was unable to maintain his grip; Mark wasdraggedovertheside,followedbythelastcreeltoggledontothefleet.Deckhand3immediatelyrantotheshootingpoles,andthrewthreelegropesoffthepoles to slacken the rope to help enable Mark to free himself from the back rope. He then ran up to the wheelhouse.

On seeing that Mark had been dragged overboard, the skipper immediately placed the engine throttle to ‘neutral’ to stop the propeller. He used the spotlight sited on top of the wheelhouse to search for Mark on the surface. Deckhand 3 then arrived on the bridge to assist the skipper in the search.

1.2.3 The rescue

Immediately after Mark had been dragged overboard, Deckhands 1 and 2 worked together to lead the back rope from the shooting hatch, through the hauling hatch and on to the creel hauler (Figure 1). They initially wound the rope on to the hauler in the wrong direction, and it took two further attempts to wind the rope on successfully. After being submerged for about 10 minutes, Mark was hauled to the surface and then recovered back on board. He was unconscious and unresponsive. Mark’s left leg was entangled in the back rope a short distance from the second creel. The deckhands released Mark from the back rope and placed him on the flakedbackrope.Theyimmediatelystartedcardiopulmonaryresuscitation(CPR)and were soon joined by the sixth crewman, who had heard the commotion.

From the CCTV display, the skipper saw that Mark was back on board and clearly in needofassistance.At1828,theskipperpressedthedigitalselectivecalling(DSC)alert button on the very high frequency (VHF) radio. This alerted the coastguard, who attempted to contact the vessel by VHF radio. At the same time, North Star’s skipper tried to call the coastguard using the VHF radio, but due to the distance between the vessel and the shore, he was unable to hear the coastguard responses. To alert the authorities, the skipper used the satellite phone to contact a director of

1 ‘Easy’indicatedthatthecrewwerefindingtherateofshootingthecreelstoofastandthevessel’sspeedneeded to be reduced.

5

Figure 3: BA Chart 002 showing the location of North Star at the time of the accident, with inset of location on BA Chart 2720

ReproducedfromAdmiraltyChart002and2720bypermissionofHMSOandtheUKHydrographicOffice

Location of North Star at time of accident

6

Scrabster Seafoods Limited, North Star’s owner. The skipper passed the director the details of the accident and North Star’s position, and asked him to notify the coastguardandtorequestassistancefromarescuehelicopter.At1830,thedirectorcalled 999 and passed details of the accident and the vessel’s position to the coastguard.

At1833,contactbetweenthecoastguardandNorth Star was established by satellite phone and the skipper gave details of the accident. He again requested helicopter assistanceand,at1834,theuseofarescuehelicopterwasapprovedandtaskedtothe scene.

By 1915, the rescue helicopter was on scene and, using VHF radio, North Star’s crew were briefed on highline techniques. North Star was moving violently in the sea and swell (Figure 4), making it impossible to attempt a highline transfer and, at 1955, the captain of the rescue helicopter informed the coastguard that he was returning to base. Following the helicopter’s departure, North Star’s skipper set a course to return to Scrabster. After administering CPR continuously for almost 90 minutes without any response, and with no prospect of external assistance, North Star’sskipperinstructedthecrewtoceasetheirresuscitationefforts.

North Star arrived at Scrabster at 0312 the following day. A local general practitioner attended the vessel, and Mark was pronounced deceased at 0430.

1.3 ENVIRONMENTAL CONDITIONS

The wind was south-west 35kts, the sea was rough and there was a north-west tidal stream of 1.5kts. It was dark and the water temperature was approximately 10°C.

Image courtesy of Maritime and Coastguard Agency

Figure 4: Image of North Star in the seaway taken from the rescue helicopter video footage

7

1.4 NORTH STAR

1.4.1 General

North Star was built in 1996. Originally named Boy Shane, the vessel operated out of Scrabster, Scotland, where its catch was landed and sold to the locally owned fish-handlingandprocessingcompany,ScrabsterSeafoodsLimited.

In November 2016, Scrabster Seafoods Limited purchased Boy Shane. It was thecompany’sfirstventureintofishingvesselownershipanditsdirectorshadnoexperienceofoperatingandmanagingfishingvessels.ThechangeofownerwasregisteredwiththeMaritimeandCoastguardAgency(MCA)andanewcertificateofregistry was issued on 21 November 2016.

In August 2017, Boy Shane was renamed North Star, and its owner removed the vesselfromserviceinorderthatitcouldundergoanextensiverefit.Theworkingdecklayoutwasmodifiedatthesametime,toreplicateanothervesselthatNorth Star’s senior skipper had seen, and whose layout he considered to be safer.

1.4.2 Survey and inspection

North Star was required to comply with The Fishing Vessels (Codes of Practice) Regulations 2017. The Regulations give statutory force to The Code of Safe Working Practice for the Construction and Use of 15 metre Length Overall (LOA) to less than 24 metre Registered Length (L) Fishing Vessels (the Code), the latest version of which came into force on 23 October 2017 and is contained within Merchant ShippingNotice(MSN)1872(F).RelevantextractsfromtheCodearereproducedatAnnex A.

AspartoftheprocessforrenewingitsUnitedKingdomFishingVesselCertificate(UKFVC), Boy Shane was surveyed by the MCA in Fraserburgh on 1 May 2014. Thesurveyidentifiedseveraldeficiencies.Asaconsequence,aseriesofshort-termUKFVCs were issued up until 31 March 2015, when a full-term UKFVC, valid until 19 April2019,wasissued.ThecertificatewasdisplayedinNorth Star’s wheelhouse.

TheUKFVCincludedthenotificationthatanintermediateinspection,tobecompleted by the MCA, was due between 20 April 2016 and 20 April 2017. When Scrabster Seafoods Limited purchased Boy Shane in November 2016, they were unaware that the intermediate inspection was due, and it was missed.

After its name change on 16 August 2017, North Star underwent a carving and marking survey. The survey was completed on behalf of the MCA by a Marine Scotland surveyor. The surveyor’s remit did not include a safety inspection.

Following the accident, an MCA surveyor conducted an inspection of North Star inScrabsteron7February2018.Thesurveyornotedanumberofdeficiencies,includingthatannualself-certificationhadnotbeencompletedbytheowner,thevessel’s risk assessments had not been reviewed, and not all crew had the required certification.Healsonotedthattheintermediateinspectionhadnotbeencompleted,and consequently detained the vessel.

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1.5 CREEL FISHING

1.5.1 Assembly of a creel fleet

Each of North Star’sfleetsofcreelsconsistedof100creels,eachweighingapproximately 20kg when dry, spaced approximately 25m apart toggled on to 9m length leg ropes. At 45m from either end of the back rope there was a steel weight (Figure 5).

1.5.2 Vessel modifications

Priortomodification,North Star was not equipped with a self-shooting system and the creels were launched manually. The creels were stowed athwartships and the backrope,whichwasalsostowedathwartships,wasflakedonthedeckbetweenthe creels and the crew (Figure 6). While stowed, the creels were toggled on to the leg ropes in series and then manhandled, one at a time, to the deckhand located at the table adjacent to the shooting and hauling hatch (Figure 6). There had been previous incidents of deckhands becoming entangled in the back rope as the creels were passed from the stow to the shooting hatch. On those occasions, either the deckhand had been able to quickly disentangle themselves from the rope or the skipper had managed to stop the vessel in the water in time to prevent the deckhand from being dragged overboard.

After modifying the working deck layout in August 2017, the back rope was stowed in a fore and aft direction, forward of the crew (Figure 7). There were no pound boards to separate the back rope from the crew; instead, the senior skipper instructed them to keep their feet on the deck to prevent their entanglement in the moving ropes. When shooting manually, a creel was placed on the table, where it was toggled on to a leg rope before being moved to the shooting hatch in readiness for it to be launched overboard. Once the shooting of creels began, the skipper varied the

Figure 5: Creel arrangement

Buoy100creelsinafleet

Pots set at 25m intervals

Back rope

45m from weight tofirstlegrope

Leg ropes 9m

Steel weight

9

Figure 6: Former working deck layout

Back ropes

Table

Hatch

Creel stow

Deckhand

10

Figure 7: Modifiedworkingdecklayout

Back ropes

Table

Table

Self-shooting hatch

Shooting poles

Deckhand

Creel stow

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vessel’s speed to control the rate at which the back rope, and hence the creels, was deployed. At a SOG of 5kts, creels were deployed at a rate of one creel every 10 seconds.

ThemodificationstoNorth Star in August 2017 included installation of a self-shooting system that could be used in weather conditions up to and including force 6 (22-27kts). Above this limit the vessel tended to ship seas across its working deck. The self-shooting system stationed the crew away from the running ropes, behind a partition. The creels were stowed in the usual athwartships position, but all weretoggledontothelegropesinsequencebeforethefirstbuoyandweightweredeployed.Thefirstbuoyandweightwerethendeployedthroughtheself-shootinghatch (Figure 7),followedbythefleetinsequence.

1.5.3 Creel shooting hazard

Anindustryadvicenotice‘PottingSafety’,publishedbySeafish2 in January 2011, offersthreemethodstoreducetheriskofcrewbeingcarriedoverboardwhileshooting creels:

● Rope pounds or divisions to physically separate crew from the back rope.

● Detachable creels using a loop and toggle system, allowing crew to work the gear in a controlled fashion while still being separated from the gear by a barrier.

● A self-shooting system that does not require manual intervention.

TheMCApublication‘Fishermen’sSafetyGuide’includesasectiononcreelfishingthat discusses the layout of working decks and recommends the provision of a physical barrier between crew and the working gear.

1.6 CREW

1.6.1 Manning

North Star’s six crew comprised three UK nationals, two Latvians and a Romanian. TheworkinglanguageonboardwasEnglish.Whenfishing,theskipperandfourdeckhands usually completed 4-5 hours of work before resting, while the sixth crewman (referred to on board as the ‘night watchman’) helmed the vessel to the next location. The crew did not routinely record their hours of work and rest on board.

1.6.2 Qualifications

FishermenservingonboardUKregisteredfishingvesselsmustcompletethemandatory safety training courses as detailed in MGN 411(M+F) – Training and CertificationRequirementsfortheCrewofFishingVesselsandtheirApplicabilityto Small Commercial Vessels and Large Yachts. Relevant extracts from MGN 411(M+F) are reproduced at Annex B. Table 1 shows the training completed by North Star’s crew.

2 Sea Fish Industry Authority

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Basic Sea Survival

Basic First Aid

Basic Fire Fighting

and Prevention

Basic Health and

Safety³

Safety Awareness and Risk

Assessment

Senior Skipper YES YES YES YES YES

Skipper YES YES YES NO YES

Deckhand 1 YES YES YES NO YES

Deckhand 2 STCW basic training NO

Deckhand 3 YES YES YES NO YES

Night watchman STCW basic training NO

Mark Elder NO NO NO NO NOTable 1: North Star’screwqualification

ThesafetytrainingcoursesareprovidedbySeafishand,whilethereisequivalenttraining that is accepted for some of the courses, none is considered to provide equivalent competency to the Safety Awareness and Risk Assessment Course.

NewentrantstofishingmustcompletetheBasicSeaSurvivaltrainingbeforetheystartworkonboardaUKfishingvessel.TheBasicFirstAid,BasicFireFightingand Prevention, and Basic Health and Safety Courses must be completed within 3monthsofstartingworkasafisherman.TheSafetyAwarenessandRiskAssessmentCourseistobeundertakenbyallfishermencomingfromoutsidetheUKandbyUKfishermenwith2ormoreyearsofexperience.

1.6.3 Senior skipper

Theseniorskipperwasa37-year-oldUKnational.Hewasacareerfishermanwhohadover20yearsoffishingexperienceandhadfirstservedasskipperin2001.Hehad served most of his career on board North Star,firstjoiningthevesselin1998during its previous ownership.

There were no written areas of responsibilities laid down for the senior skipper, and following the vessel’s change of ownership he had carried on with his duties under the new owner as he had under the previous owner. He assumed responsibility for the day-to-day running of the vessel and liaised with the owner on maintenance issues.

3 FollowingthediscoverythatmanyexperiencedfishermenwhojoinedtheUKfishingindustryafter1January2005 had not completed the mandatory Basic Health and Safety Course, the MCA decided: ‘FishermenwhojoinedaUKfishingvesselforthefirsttimeafter1January2005andbefore1June2014anddid not undertake the Basic Health and Safety Course do not have to complete this course provided that they: a) have completed the Safety Awareness and Risk Assessment Course and b) can demonstrate the date of joining a UK vessel prior to 2014 to the satisfaction of an MCA surveyor. FishermenwhojoinedaUKfishingvesselforthefirsttimeafter1June2014anddidnotundertaketheUKBasicHealthandSafetyCoursemustcompletethiscoursewithinatimespecifiedbyanMCAsurveyor.ThisappliesregardlessofwhetherthefishermanholdstheSafetyAwarenessandRiskAssessmentCourse.’

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The senior skipper, who was not on board North Star at the time of the accident, shared the role of skipper with a relief skipper on an ad-hoc basis that depended on their respective availability.

1.6.4 Skipper

The relief skipper, who was the skipper on board North Star at the time of the accident,wasa30-year-oldUKnational.Hehadbeenfishingsincehewas14,anddidnotholdaskipper’scertificate.Atthestartofhiscareer,theskipperhadservedon board Boy Shane as a deckhand, but he had left to join another vessel. He re-joined North Star as skipper in January 2017.

1.6.5 Mark Elder

Mark Elder was a 26-year-old UK national. He was an employee of Scrabster Seafoods Limited working on a zero hours’ contract in the company’s factory. Mark had actively sought to join the crew of North Star, and this was his seventh voyage on board.

Markwashealthconscious,physicallyfit,andregularlyvisitedthegym.Hewas1.80mtall,weighed70kgandwasreportedlyastrongswimmer.WhenMarkwasdragged overboard he was wearing casual clothing, oilskins and wellington boots.

The postmortem report stated that Mark had abrasions on his limbs and, notably, an almost circumferential abrasion around his left upper leg. The report stated that the cause of death was drowning.

Mark was a recreational user of cannabis and the toxicology report stated that he had 11-Nor-9-carboxy-tetrahydrocannabinol4 in his urine. The pathologist noted:

‘Cannabis metabolite was present in his urine although this can be detected for a number of days after use and there was no evidence of other drug use.’

1.6.6 Cannabis

Cannabis is the most widely used illegal drug in Great Britain. There are four differenttypesofcannabis,andtheyvaryinbothstrengthandpopularity.

Cannabisisbothasedatingandhallucinogenicdrug,anditseffectsrangefrommaking a person feel relaxed and happy, to inducing feelings of panic and paranoia. Hungerisalsoacommonsideeffect.Whenundertheinfluenceofcannabisanindividual’s concentration may be poor and a lack of motivation may also be evident.

1.7 ONBOARD SAFETY

1.7.1 Health and safety general duty

In accordance with Regulation 5 of The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 (Statutory Instrument 1997, No 2962), an employer has a general duty to:

‘ensure the health and safety of workers and other persons so far as is reasonably practicable’.

4 The by-product of imbibed cannabis

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The principles of this general duty applicable to North Star’s owner included, inter alia:

● Avoiding or minimising risks

● Evaluating unavoidable risks and taking action to minimise them

● Adopting safe work patterns and procedures, and

● Providing appropriate and relevant information and instructions for workers.

Inpractice,theskippercontrolledday-to-daysafetymanagementoffishingoperations on board North Star. When new crew joined the vessel, the senior skipper conducted a brief induction that included an explanation of the use and location of the safety equipment provided on board. No records of inductions were kept.

1.7.2 Risk assessment

MSN1872(F)states:

‘1.3.9.1 Risk assessments of the vessel are particular to each owner. When a vessel is sold, the new owner shall complete, or arrange for the completion of, a new risk assessment and new annual self-certification5.’

North Star had on board a Fishing Vessel Safety Policy Statement that contained riskassessments,andastatementtotheeffectthattheriskassessmentswouldbereviewedevery12monthsorsoonerifsignificantchangesweremade.Theseniorskipper had completed the risk assessments on 14 March 2005 and had reviewed them on 25 April 2014 prior to the renewal of the vessel’s UKFVC. No further review was conducted until after the accident. The rest of the crew, including the relief skipper, were unaware of the risk assessments on board.

The risk assessments for ‘general working on the deck, ‘shooting general’ and ‘potting’ are reproduced at Annex C.

1.7.3 Emergency preparedness

MSN1872(F),Chapter8(EmergencyProcedures)requiresmonthlyemergencydrills to be completed and recorded. Marine Guidance Note (MGN) 570(F) – Fishing Vessels–emergencydrills–providesguidanceonscenariosfordifferenttypesofemergency drills. It draws particular attention to preparing for a man overboard by conducting manoverboard drills to familiarise crew with the required procedures.

MGN 571(F) – Fishing Vessels: Prevention of Man Overboard – acknowledges that although MGN 570(F) provides guidance on responding to man overboard emergencies,

‘…it is clear that falling overboard is highly likely to result in death and therefore it is better to prevent Man Overboard from happening.’

5 Annualself-certificationisayearlywrittendeclarationbytheownerontheUKFVCthat,interalia,theriskassessmentsremainappropriatetothevessel’sfishingmethodandmodeofoperation,andthatcrewtrainingandcertificationarevalid.

15

MGN 571(F) provides guidance on how to assess the risk of going overboard and preventing it from happening. Where the risk cannot be removed by eliminating or isolatingtheidentifiedhazards,itrecommendsthewearingofaPersonalFlotationDevice (PFD).

There was no record of safety drills maintained on board North Star and practical drills were not held. Safety talks were held when emergency procedures - such as manoverboard - were discussed. Crew were shown where safety equipment was stowed, although the equipment was neither used nor demonstrated. None of the crew wore a PFD when working on deck.

The MCA publication ‘Fishermen’s Safety Guide’ warns that familiar and repeated taskscancauselapsesinconcentration,andadvisesfishermentohaveasharpknife to hand for use in an emergency. Mark did not carry a knife and there were no knives available in the vicinity of the shooting hatch.

1.8 COLD WATER IMMERSION

Sudden immersion in cold water (under 15ºC) can result in cold water shock and/or cold incapacitation:

1. Cold water shock

Coldwatershocktakesplacewithinthefirst30secondsto2minutesandisgenerallyassociatedwithagaspreflexasthebodycomesintocontactwiththecold water, along with hyperventilation and a dramatic increase in heart rate and blood pressure. If the head goes underwater during this stage, the inability toholdone’sbreathwilloftenleadtowaterenteringthelungsinsufficientquantities to cause death. The increased heart rate and blood pressure can result in cardiac arrest, especially if the casualty has an existing cardiovascular condition. Panic can cause the hyperventilation to continue even after the initial physiologicaleffectshavesubsided.

2. Cold incapacitation

Cold incapacitation usually occurs within 2-15 minutes of entering the water. The blood vessels are constricted as the body tries to preserve heat and protectvitalorgans.Thisresultsinthebloodflowtotheextremitiesbeingrestricted, causing cooling and consequent deterioration in the functioning of muscles and nerve ends. Useful movement is lost in the hands and feet, progressively leading to the incapacitation of arms and legs. Unless a PFD is worn, death by drowning occurs as a result of impaired swimming.

1.9 SKIPPER/OWNER RESPONSIBILITIES

At the time of writing this report the MCA was undertaking a public consultation in respect of proposed measures to implement the International Labour Organization WorkinFishingConvention,ILO1886.ThemeasuresrecognisethatwhileafishingvesselownerhasoverallresponsibilityforhealthandsafetyonboardUKfishingvessels, they have limited control of day-to-day activities, and therefore must set the health and safety policy for the vessel so that the skipper is clear on what is

6 ILO188cameintoforceinternationallyon16November2017,butisnotyetinforceintheUK.

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expected. In this regard, the MCA will expect skippers to have responsibility for the safetyoffishermenonboardthevesselandthesafeoperationofthevessel.Thisisto include:

● Providingsupervisiontoensurethatfishermenworksafelyatalltimes.

● Managingfishermeninamannerthatrespectshealthandsafety.

● Arranging regular onboard health and safety awareness training.

● Ensuring compliance with good navigation and watchkeeping standards.

1.10 PREVIOUS ACCIDENTS

1.10.1 Varuna

On 20 November 2017, the single-handed creel boat Varuna was found aground and unmanned on a small island. Varuna had left its mooring earlier in the day and had beenseenworkingcreelfleets.

An extensive sea, land and air search failed to locate the skipper, who had been the only person on board. His body was found washed ashore almost 3 weeks after the accident. The skipper did not routinely wear a PFD, and it is likely that he fell overboard during Varuna’s return passage to port.

The MAIB investigation7 concluded that by not wearing a PFD, the skipper’s chances ofsurvivalafterenteringthewaterweresignificantlyreduced.ItalsoconcludedthattheMCAneedstoadoptmeasurestoensureitsoversightofcommercialfishingiseffective.

1.10.2 Pauline Mary

On2September2016,thecrewmanonboardthefishingvesselPauline Mary was dragged overboard after becoming entangled in the gear while shooting pots. When the crewman was recovered back on board about 20 minutes later, he was not breathingand,despitetheeffortsoftheskipperandtheemergencyservices,couldnot be resuscitated.

The MAIB investigation8identifiedthattherewasnophysicalseparationbetweenthecrew and the back rope. The crewman was also neither carrying a knife nor wearing a PFD, both of which could have improved his chances of survival.

7 MAIBReport13/2018: https://www.gov.uk/maib-reports/man-overboard-from-creel-fishing-vessel-varuna-with-loss-of-1-life

8 MAIBReport8/2017: https://www.gov.uk/maib-reports/man-overboard-from-potting-fishing-vessel-pauline-mary-with-the-loss-of-1-life

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SECTION 2 - ANALYSIS

2.1 AIM

The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future.

2.2 THE ACCIDENT

MarkElder’sleftlegbecameentangledinthebackropeofafleetofcreelsthatwere being shot from North Star. The crew were unable to free him before he was dragged overboard. Once immersed, he was unable to free himself. By the time the crew were able to recover him back on board, he was unconscious and unresponsive,andthecrew’seffortsatCPRwereunsuccessfulinrevivinghim.

2.3 ENTANGLEMENT

2.3.1 Entanglement in the gear

ThedangersofcreelfishingarehighlightedbytheMCAinits‘Fishermen’sSafetyGuide’,andbySeafishinits‘PottingSafety’industryadvisorynotice.Bothpublications illustrate the perils of standing in a rope bight, and emphasise the importance of keeping clear of moving ropes, particularly when shooting creels. Physical barriers, such as pound boards, are suggested as means of providing separation between crew and moving ropes. North Star’sworkingdeckmodificationcompleted in August 2017 was aimed at making the shooting operations safer. However,themodificationsdidnotprovideaneffectivephysicalseparationbetweenthe crew and back rope during manual shooting operations.

Without a physical barrier to prevent Mark from becoming entangled in the back rope, he was in an extremely precarious position that relied on his ability to keep his feet on the deck. In the rough seas, North Star was moving violently (Figure 4) and, given the rate at which the creels were being shot, Mark is likely to have been more focused on toggling the creels on to the leg ropes rather than on keeping his feetflatondeck.Hethereforeinadvertentlysteppedintoabightofbackrope.Asthe‘Fishermen’s Safety Guide’ warns, familiar and repeated tasks can cause lapses of concentration.

There had been previous incidents of North Star’s crew becoming entangled in the running back rope. However, on those occasions either the deckhand had been able to quickly disentangle themselves from the rope or the skipper had managed to stop the vessel in the water in time to prevent the deckhand from being dragged overboard.

That there was no negative outcome from these incidents, together with the perceived ‘safer’ manual shooting arrangement, probably contributed to both Mark and the remaining crew underestimating the risks associated with the back rope.

A lack of physical separation between the crew and the back rope during shooting operationswasasafetyissueidentifiedintheMAIB’sPauline Mary investigation, andboththeSeafishPottingSafetyAdviceandthe‘Fishermen’sSafetyGuide’

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cautiontheneedtoeffectivelyseparatecrewfromthemovingbackrope.Itistherefore a matter of concern that this essential safety guidance continues to be ignored.

2.3.2 Dragged overboard

Although North Star’s skipper was already reducing the vessel’s speed when the crew raised the alarm, he was unable to stop the vessel in time to prevent Mark from being dragged overboard. Given the rate at which the creels were being deployed, and without a knife readily available to cut Mark free of the back rope, there was little else that Mark, or anyone else, could do to prevent him from going overboard. The‘Fishermen’sSafetyGuide’advisesfishermentohaveasharpknifetohandforuse in an emergency. However, North Star’s documented risk assessment did not identify knives as a risk control measure, and there were no knives available for use in the vicinity of the shooting hatch.

2.4 IN WATER SURVIVABILITY

Once Mark had entered the water, his only connection with North Star was the back rope that was wrapped around his left leg. This rope was weighed down on bothsidesbycreels,andwithoutaknifetohanditwouldhavebeendifficult,ifnotimpossible, to free himself before drowning.

Although Mark had completed six voyages on board North Star, he had not undertaken the mandatory Basic Sea Survival safety training course. Consequently, he was ill-prepared for sudden cold water immersion. Although Mark was reportedly a strong swimmer and in good physical health, he still might have succumbed to the effectsofcoldwatershock.

However, had Mark survived initial cold water shock and had been able to free himself from the back rope, he would then have been at risk of drowning through cold incapacitation unless he was wearing a PFD and/or was able to be recovered quickly from the water. Contrary to the guidance provided in MGN 571(F), neither Mark nor the remaining crew of North Star wore a PFD when working on deck.

The MAIB’s Pauline Mary investigationidentifiedthatthecarryingofaknifecouldhave improved the crewman’s chances of survival after he had been dragged overboard. Additionally, both that and the MAIB’s Varuna investigation concluded that the wearing of a PFD could have increased survivability in each case. Although the utility of a PFD would have been contingent on Mark’s ability to free himself from the back rope, without it his chances of surviving a man overboard, into water of 10ºC, were much reduced.

2.5 THE RESCUE

During the manoverboard recovery, it took North Star’s deckhands several attempts to correctly wind the back rope on to the hauler to heave it in and so recover Mark backonboard.UKfishermenaretaughttheprinciplesofmanoverboardrecoverywhen they complete the mandatory Basic Sea Survival and Safety Awareness and Risk Assessment safety training courses. However, when faced with a real-time situation, unless the initial training has been reinforced with onboard training in the form of practice drills, the crew are likely to be ill-prepared for an emergency.

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Although there had been previous incidents of a deckhand becoming entangled in the back rope, either the deckhand had been able to quickly disentangle themselves from the rope or the skipper had managed to stop the vessel in the water in time to prevent the deckhand from being dragged overboard. The crew werethereforeconfidentthatamanoverboardcouldbeavoidedfollowinganyfutureentanglements. The safety drills held on board North Star had been ‘discussions’ rather than practical exercises that would have allowed the crew to practise manoverboard procedures in accordance with the guidance provided in MGN 570(F). Had practical drills been held on board North Star, the crew would have been better prepared for the emergency.

Although there was a delay in recovering Mark back on board, the skipper was quick toalerttheemergencyservices,andthecontinuouseffortsofthecrewtoreviveMark over a period of almost 90 minutes were commendable.

2.6 SAFETY CULTURE

2.6.1 Responsibilities

North Star’s owner, Scrabster Seafoods Limited, was required to comply with the Code of Safe Working Practice for the Construction and Use of 15 metre Length Overall (LOA) to less than 24 metre Registered Length (L) Fishing Vessels. In particular, on taking ownership of North Star in November 2016, the owner or a delegated representative was required to complete new risk assessments and vesselself-certification.Theself-certificationwastoberepeatedannuallytoconfirm,amongotherthings,thattheriskassessmentsremainedappropriatetothevessel’sfishingmethodandmodeofoperation,andthatcrewtrainingandcertificationwerevalid.Furthermore,theownerwasrequiredtoapplytotheMCAfor an intermediate inspection of North Star to be conducted in what remained of the period between 20 April 2016 and 20 April 2017 in which it was due.

ScrabsterSeafoodsLimitedwasnewtofishingvesselownership,andsowas unaware of the above requirements. North Star’s risk assessments and UKFVC were kept on board the vessel, and the owner left the day-to-day safety managementoffishingoperationsunderthecontroloftheskipper.However,therewere no written delegations of responsibility to the skipper, and the senior skipper had continued with his duties as he had under the previous owner. These duties were limited to the day-to-day running of the vessel and liaising with the owner on maintenance issues. Neither the owner nor the senior skipper was proactive in ensuring that the applicable regulatory requirements were met or that published industry best practice was being followed. Consequently, North Star’s intermediate inspection was missed, the vessel’s documented risk assessments were not reviewed,annualself-certificationwasnotcarriedout,andnotallcrewhadtherequiredsafetytrainingcoursecertification.

The changes to UK legislation proposed by the MCA in respect of measures to implementILO188shouldreaffirmthatwhiletheownerhasoverallresponsibilityforhealth and safety on board its vessels, it has limited control of day-to-day activities. Owners therefore must set out the health and safety policy for their vessels so that skippers are clear on their delegated responsibilities. However, this will still require aproactiveapproachtohealthandsafetybybothownersandskippersforeffectivepolicies to be established and implemented.

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2.6.2 Risk assessment

North Star’s documented risk assessments had been completed on 14 March 2005. Theriskassessmentsidentifieda‘veryunlikely’hazardofacrewmemberbecomingentangled in rope and being dragged overboard, and required risk controls of ropes to be kept in a pound and crew to remain clear of the back rope during shooting operations.Thevessel’sworkingdecklayoutbothbeforeandafterthemodificationcompleted in August 2017 required crew to work in close proximity to the back ropewithnoeffectivephysicalseparationduringshootingoperations.Therefore,thedocumentedriskcontrolsdidnotreflecttheoperationalpracticeonboard,andthe risk of a deckhand becoming entangled in the back rope and being dragged overboard remained high. The senior skipper’s instruction for crew to keep their feetonthedeckduringshootingoperationsfellshortofbeinganeffectivecontrolmeasure and demonstrated an underestimation of the risks involved.

The risk assessments had been completed by the senior skipper, but they were not shared with any of the crew, including the relief skipper. They had not been reviewed after the change of ownership in November 2016 or following the working deckmodificationinAugust2017.Infact,itisevidentthattheriskassessmentswere‘reviewed’ only once before the accident, when no changes were made, on 25 April 2014 just prior to the renewal of the vessel’s UKFVC.

Riskassessmentshavebeenrequiredonboardfishingvesselssince1998,andfishermenhavebetterengagedwiththeminrecentyears.However,asisevidentfrom the circumstances of this accident, more is needed to convince owners and fishermenthatriskassessmentsareavaluabletoolforimprovingsafetyandprotecting lives.

While North Star’s risk assessments required physical separation between the crew and the back rope, they did not identify a need for crew to carry knives or to wear aPFDduringshootingoperations.Withoutsuitableandsufficientriskassessmentsto identify hazards, implementation of applicable risk controls to mitigate those hazards,andannualself-certificationtoconfirmthatriskassessmentsremainappropriateandthatcrewtrainingandcertificationremainvalid,thesafetyofNorth Star and its crew was compromised.

The safety culture on board a vessel is the product of individual and collective perceptions, competencies and values that determine an owner and crew’s attitude to health and safety. Fishing vessels with a strong safety culture are those that are risk averse, resilient, adhere to regulatory requirements and industry best practice, andemploycompetentcrew.Asaresult,theytypicallyhavefewerdeficiencies,fewer accidents, and less resultant downtime.

2.7 REGULATORY OVERSIGHT

Afishingvesselof15mormoreLOAisnotrequiredtoundergoanMCAsafetyinspection on change of ownership. Consequently, there was no requirement for the MCA to conduct a safety inspection of North Star following its issue of a UKFVC on 31 March 2015 until 20 April 2017, which was the latest time by when an intermediate inspection was required to be completed.

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The MCA relied on a new owner completing, or arranging for the completion of new riskassessmentsandvesselself-certification,andapplyingforanintermediateinspectiontobecarriedout.ScrabsterSeafoodsLimitedwasnewtofishingvesselownership and was unaware of the above requirements. It was not until the MCA’s post-accidentinspectionon7February2018thatitbecameapparentthatself-certificationhadnotbeencompleted,thevessel’sriskassessmentshadnotbeenreviewed,notallcrewhadtherequiredcertification,andanintermediateinspectionhad not been completed.

The MAIB’s Varuna investigation concluded that the MCA needs to ensure its oversightofcommercialfishingiseffective.Inthisregard,newowners,orthosewithlimitedexperienceofcommercialfishing,wouldbenefitfromtheMCAtakinga proactive approach to informing them of applicable regulatory requirements and published industry best practice. Additionally, although not a mandatory requirement, a safety inspection by the MCA following a change of vessel ownership would provide reassurance that the new owner was aware of its obligations, the vessel’s riskassessmentshadbeenreviewed,self-certificationhadbeenconducted,andcrewtrainingandcertificationwerevalid.Furthermore,aproactiveapproachbythe MCA to provide a timely reminder to the owner to apply for a due survey or inspection would help ensure it was not missed.

2.8 DRUG USE ON BOARD FISHING VESSELS

Mark’s use of cannabis cannot be attributed to his time on board North Star, however the possibility that he took it while on board cannot be eliminated. Therefore,itisdifficulttostatewithanydegreeofconfidencewhateffects,ifany,Mark was experiencing from the drug at the time of the accident.

ThisisnotthefirsttimetheMAIBhasinvestigatedanaccidentwheredrugusehasbeen evident. Fishing vessels are potentially dangerous workplaces, and owners need to ensure, to the best extent possible, that crews are able to perform both their routine and emergency duties when required. The use of recreational drugs should be discouraged, and if appropriate a robust drug and alcohol policy adopted.

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SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. There was no physical barrier to prevent Mark from becoming entangled in the back rope. [2.3.1]

2. Previous similar incidents on North Star in which a man overboard had been prevented, together with a perceived ‘safer’ manual shooting arrangement, probably contributed to both Mark and the remaining crew underestimating the risks associated with the back rope. [2.3.1]

3. Without a knife readily available to cut Mark free of the back rope, there was little else that Mark, or anyone else, could do to prevent him from going overboard. [2.3.2]

4. North Star’s documented risk assessment did not identify knives as a risk control measure, and there were no knives available for use in the vicinity of the shooting hatch. [2.3.2]

5. Withoutaknifetohand,itwouldhavebeendifficult,ifnotimpossible,forMarktofree himself from the back rope before drowning. [2.4]

6. Mark had not undertaken the mandatory Basic Sea Survival safety training course. Consequently, he was ill-prepared for sudden cold water immersion, and might have succumbedtotheeffectsofcoldwatershock.[2.4]

7. The safety drills held on board North Star had been ‘discussions’ rather than practical exercises that would have allowed the crew to practise manoverboard procedures. [2.5]

8. Neither the owner nor the senior skipper was proactive in ensuring that the applicable regulatory requirements were met or that published industry best practice was being followed. [2.6.1]

9. North Star’sdocumentedriskcontrolsdidnotreflecttheoperationalpracticeonboardand,followingamodificationtotheworkingdecklayout,theriskofadeckhand becoming entangled in the back rope remained high. [2.6.2]

10. The MCA relied on a new owner completing, or arranging for the completion of, newriskassessmentsandvesselself-certification,andapplyingforanintermediateinspection to be carried out. [2.7]

11. ItispossiblethatMark’sconcentrationwasadverselyaffectedbyhisuseofcannabis.[2.8]

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3.2 OTHER SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT9

1. ItispossiblethatMark’sconcentrationwasadverselyaffectedbythefamiliarandrepeated task of hauling and shooting creels. [2.3.1]

3.3 SAFETY ISSUES NOT DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. Had Mark survived initial cold water shock and had he been able to free himself from the back rope, he would have been at risk of drowning through cold incapacitation unless he was wearing a PFD and/or was able to be recovered quickly from the water. [2.4]

9 These safety issues identify lessons to be learned. They do not merit a safety recommendation based on this investigation alone. However, they may be used for analysing trends in marine accidents or in support of a future safety recommendation.

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SECTION 4 - ACTION TAKEN

4.1 ACTIONS TAKEN BY MAIB

The Marine Accident Investigation Branch has:

● Issued a Safety Flyer to the Fishing Industry (Annex D).

● FormallyrespondedtotheconsultationonILO188legislationemphasisingtheneedfortheimpendinglegislationtoaddresssafetyissuesidentifiedinthisreport.

4.2 ACTIONS TAKEN BY OTHER ORGANISATIONS

Scrabster Seafoods Limited has:

● Installed a physical barrier (pound board) to reduce the risk of crew from becoming entangled in the back rope.

● Equipped the vessel with PFDs.

● Ensured that North Star’s crew have attended the mandatory safety training courses.

● Reviewed the vessel’s risk assessments.

● Introduced a drugs and alcohol policy for North Star’s crew.

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SECTION 5 - RECOMMENDATIONS

Scrabster Seafoods Limited is recommended to:

2018/130 Improve the overall safety of its crews by ensuring that:

● Documentedriskassessmentsremainappropriatetothevessel’sfishingoperationandreflectindustrybestpractice.

● Annualself-certificationisconducted,riskassessmentsarereviewedatleastannually,andcrewtrainingandcertificationremainvalid.

● Mandatory vessel surveys and inspections are applied for at the required times.

● Practical emergency drills are conducted at least monthly and in accordance with industry best practice.

● Skippers are clear on their delegated responsibilities in implementing the vessel’s health and safety policy.

The Maritime and Coastguard Agency is recommended to:

2018/131 Improveitssupporttocommercialfishingvesselownersby:

● Providingnewownersoffishingvesselswithguidanceontheapplicableregulatory requirements and published best practice.

● Conductingasafetyinspectionfollowingachangeoffishingvesselownership.

● Providingtimelyreminderstofishingvesselownersoftheneedtoapplyfordue surveys and inspections.

Safety recommendations shall in no case create a presumption of blame or liability

Marin

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